Editorial note: As Britain descends into an orgy of handwringing about the abuse of vulnerable people, this is the first of several posts to tackle the issue.
In 2000 when I gave a lecture on Psychopharmacology and the Government of the Self at the invitation of the University of Toronto, I ran into a problem. In the public domain our shared difficulties were because of this lecture. In fact, the difficulties stemmed from a member of the Establishment – Charlie Nemeroff – who put the frighteners on the University of Toronto about hiring Healy.
The psychopharmacology establishment in the face of adverse effects from drugs is the same as the medical establishment in the face of treatment related adverse effects is the same as the British establishment in the face of allegations of paedophilia and child abuse is the same as the Vatican in the face of allegations of abuse.
It’s about power. We have it – you don’t. Get lost.
There is maybe a difference in that it could be argued that academics are just middle men these days rather than holders of real power – but sometimes the less power the more vicious and nasty the abuse.
Psychopharmacology and the government of the self
The lecture had twenty-six slides, of which all bar one were images. It can be accessed here.
The main point was that the face of medicine was changing.
At the heart of this change was the fact that drug development now went through clinical trial programs and the data from these trials were now hidden. Because of this we were in an increasing darkness about the hazards of treatment. Not just specific hazards but the very idea that there might be hazards was being lost. There was no way to keep a check on things. This was a call for access to clinical trial data long before AllTrials or Tamiflu were heard of.
The lecture was widely misreported as Healy said SSRIs cause suicide. The message was that I believe SSRIs cause suicide, you in the audience likely don’t – the difference stems from the fact that you haven’t seen and cannot get to see what I have seen.
Against this background conflict of interest was an issue of growing importance – we were increasingly dependent on the people we might turn to if things went wrong – the police in the case of abuse, bishops in case of clerical abuse, academics in the case of pharmacological abuse – or perhaps members of a Hospital or Health Board.
As a way to illustrate the point, one of the 26 images used was that of Harold Shipman. Shipman was a doctor whose case was then dominating the headlines of British and world medical care. He had murdered hundreds of his patients, mostly women. There seemed to be some gain in terms of getting their wills altered so he was given money, but no-one believed this was enough to explain what had happened. He seemed to enjoy it.
We were I said creating conditions in which Shipmans could flourish.
From hero to villain
Baron von Munchausen was a real life eighteenth century German, a colorful character who traveled widely and developed a reputation for tall tales. There was nothing wrong with his health – physical or mental. But he has posthumously been done in.
In 1951, a British doctor describing three cases of patients who were feigning illnesses behind the smokescreen of colorful stories suggested describing this condition as Munchausen’s Syndrome. The patients were thought to be trying to pass themselves off as ill in order to gain attention or sympathy. The Baron, as a result, is probably now thought by most people who hear of Munchausen’s Syndrome as someone who was mentally ill.
In the mid-1970s a new disorder emerged – Munchausen’s Syndrome by Proxy. In this case parents were thought to be making their children ill, in some cases close to killing them, in order to gain medical attention.
Proxy Munchausen’s has given rise to huge controversy. There was a rush to label parents in cases doctors found difficult as sufferers. Some of the parents fought back and won. The reputations of several leading doctors who had branded parents injudiciously were destroyed.
Everyone agrees that the original syndrome is pretty rare and the proxy variant is even rarer – I may have seen one convincing case of the proxy syndrome in my career.
The dynamics of abuse
But just as Tall Tales take on a life of their own, the idea of Munchausen’s syndrome has penetrated deep into healthcare. It seems to shape shift as it goes. Mental health workers now faced with an awkward patient protesting that the treatment they are on is not suiting bizarrely describe these “awkward” people as suffering from Munchausen’s, with an awkward mother complaining about the treatment her son is being put on being labeled Munchausen’s by Proxy.
This is exactly the opposite to the original syndrome. In this case people with a real illness, who are being given a very real second problem, are being termed fantasists. Why?
With all abuse, dynamics come into play. In the case of priests, or Britain’s most famous abuser Sir Jimmy Saville, the sheen of good works makes it almost impossible for others aside from the victim to see the dark side. It’s just difficult to hold two contradictory things in our mind at the same time.
In medicine, blaming the patient or a relative is the perfect way to hide the identity of the real abuser – the doctor.
Doctor Munchausen is not an uncommon figure. He or she is the one who gives you illnesses which they then feed off. There is one – likely several – working in every hospital in the land – from Bangor in Wales through to Sydney in New South Wales, from Seattle to Dr Nemeroff’s new stomping ground in Miami, from Vancouver to Halifax, from Belo Horizonte where the dream died to Buenos Aires where Jorge Mario Bergoglio comes from. Europe is stuffed full of them from Helsinki through Berlin to Lisboa.
The mechanism of abuse
The mechanism of abuse is very PC – a prescribing cascade. When a problem develops on treatment you are put on more of the same treatment or further drugs are added in to treat the original problem and unless you have a lucky escape or have extraordinary courage, the abuse keeps going until you are dead. Doctors who abuse are concealed by the fact they are doing even more of what good doctors do than their colleagues.
Caught like a child in the soft fleshy hands of a priest, it’s almost impossible to escape. No-one will believe you – not the doctors’ colleagues, not the management of a Hospital, especially if the abuser is one of them, not any of the regulatory bodies in health nor the government.
It’s difficult to know whether the mental health system is worse than the rest of healthcare. Here the abuser has the power to forcibly detain a perfectly normal person in hospital who might for instance be suffering a very clear physical reaction to treatment and threaten them with shock therapy. One Flew Over the Cuckoo’s Nest is not something that happened back then – it happens today and will happen tomorrow and tomorrow and tomorrow in mental healthcare but typically with antipsychotics rather than ECT.
There seems to be no protection. This can happen in hospital settings where the boss may have once have been responsible for making sure that vulnerable patients are not abused by the Mental Health Act. Once a person with this kind of background swaps sides and becomes part of the system and it’s a case of stopping a person who sits across the table from them from abusing someone, they seem unable to do it. The abusers are Welt-Meisters – Masters of their little Universes.
Descent into hell
Following Shipman, there was an orgy of efforts to make sure this couldn’t happen again. British doctors now have to be revalidated, regulatory bodies have more teeth, the checks are ever more thorough. But all this does is to penalize the good doctor without in any way stopping or deterring the most profound abuse. The abuser is now in fact even more protected by a battery of boxes ticked and forms filled – if it is to survive, the system cannot let them be fingered as abusive.
Last week, following revelations of pedophile rings operating at the highest echelons of British society, Britain began its descent into another orgy of hand-wringing – how do we stop the powerful doing these things.
The place on this earth where there is the greatest mismatch in power between two people is when doctors meet patients. The easiest place on this earth for an abuser to flourish is in a doctor’s office. Have a look there.